ISMP (Institute for Safe Medication Practices) has long been
the “go to” resource for information and tools regarding medication safety. One
of ISMP’s most valuable medication safety tools is its List
of High-Alert Medications. ISMP recently updated that list, based upon
review of errors submitted to the ISMP National Medication Errors Reporting
Program (ISMP MERP), literature review, input from various safety experts, and
responses to a survey of readers of ISMP newsletters.
Survey respondents most frequently identified the following
medications: anticoagulants, insulin, neuromuscular blocking agents,
chemotherapy, opioids, hypertonic sodium chloride injection (concentrations
greater than 0.9%), adrenergic agonists, and other concentrated electrolytes.
See ISMP’s newsletter (ISMP
2018) detailing the responses to the survey and the deliberations that went
into their update of the list. Several additions were made to the list:
Other changes included:
Hospitals and ambulatory sites are required to have lists of
high-alert medications (Joint Commission standard). The list of high-alert
medications will vary from hospital to hospital, depending upon the pattern of
medication use most prevalent at each hospital. For example, the list at a
behavioral health facility will likely differ from that at a general hospital,
and that at a pediatric hospital will likely be different from both.
Hospitals may well include some drugs not on ISMP’s list.
While drugs on the list are usually those frequently prescribed at the
hospital, we also caution hospitals to consider putting on the list drugs that
may be dangerous and which their staff may be relatively unfamiliar with. For
example, we recommend hospitals consider including desmopressin on their list.
Particularly since this drug is being prescribed more and more for treatment of
nocturia, patients are showing up in the hospital who have been on it at home.
Staff are frequently unfamiliar with it and the
other medical conditions that led to the hospitalization may render the patient
even more vulnerable to the unwanted side effects of desmopressin. We refer you
to our Patient Safety Tips of the Week for March 18, 2008 “Is
Desmopressin on Your List of Hi Alert Medications?” and October 25,
2016 “Desmopressin
Back in the Spotlight” for details.
One surprising finding in the responses to ISMP’s recent
survey was that, even though almost all hospitals had a high-alert drug list,
only 64% reported that they utilized special precautions to minimize and
prevent errors for all of the high-alert medications
on their list. The whole point of such a list is not only to alert all staff to
the dangers but also to provide guidance about precautions to minimize risk of
these agents.
References:
ISMP (Institute for Safe Medication Practices). High-Alert
Medication Survey Results Lead to Several Changes for 2018. ISMP Medication
Safety Alert! Acute Care Edition 2018; 23(17): August 23, 2018
http://www.ismp.org/resources/high-alert-medication-survey-results-lead-several-changes-2018
ISMP (Institute for Safe Medication Practices). High-Alert
Medications in Acute Care Settings. August 23, 2018
http://www.ismp.org/recommendations/high-alert-medications-acute-list
Print “September
2018 ISMP Updates List of High-Alert Medications”
One of our most frequent topics has been communication
errors that cause diagnostic errors and delays that may lead to disastrous
patient outcomes (see list of columns at the end of today’s column). Recently,
there have been several initiatives or studies that have expounded upon this
issue.
ECRI Institute partnered with multiple organizations and
convened an expert advisory panel to address the issues of errors or delays in
diagnosis related to failure to follow up and errors related to changes or
discontinuation of medications (ECRI
Institute 2018). That Partnership for Health IT Patient Safety identified three
key safe practice recommendations:
We hope you’ll access the ECRI Partnership toolkit
which also contains an excellent slide presentation. The report and toolkit are
very valuable resources that every healthcare organization can benefit from.
Meanwhile, our neighbors to the north have launched a
campaign Greg’s Wings, highlighted by the
film Falling Through the
Cracks: Greg's Story. This is a powerful story of how failures in
communication (“no news is good news”) led to diagnostic and therapeutic delays
and ultimately the death of a young man. You’ve heard us so many times use the
phrase “stories, not statistics” to drive buy-in from healthcare workers in a
variety of patient safety issues. This film provides such a story.
One of the salient features in Greg’s Story is faxed
referrals to specialists being lost and ignored. We highlighted the surprising
continued role faxes play in healthcare and the problems associated with them
in our January 16, 2018 Patient Safety Tip of the Week “Just
the Fax, Ma’am”. An editorial in the Canadian press (Picard
2018) notes that, just as in the US, Canadian physicians still rely
primarily on fax for communication with other physicians, despite the fact most
have electronic medical record systems.
And failures in communication about diagnoses also happen
when patients are transferred from one hospital to another. A recent study from
University of Minnesota researchers (Usher 2018) looked at adult patients
transferred between 473 acute care hospitals from 5 states from 2011 to 2013.
The researchers found that discordance in diagnoses occurred in 85.5% of all
patients. 73% of patients gained a new diagnosis following transfer while 47%
of patients lost a diagnosis. Moreover, diagnostic discordance was associated
with increased adjusted inpatient mortality (OR 1.11).
But when both involved hospitals shared data via health
information exchange (HIE) there was a reduced diagnostic discordance index
(3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).
All these endeavors highlight the need for better
communication on multiple levels in the healthcare continuum to reduce
diagnostic errors and delays that may lead to adverse patient outcomes.
See also our other
columns on communicating significant results:
Some of our prior
columns on diagnostic error:
References:
ECRI Institute. ECRI Institute's Partnership for Health IT
Patient Safety Releases New Recommendations to Avoid Testing and Medication
Mix-ups. Publicly available report offers important tools and guidance for all
healthcare systems. ECRI Institute 2018; Press release July 26, 2018
Partnership for Health IT Patient Safety. Health IT Safe
Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect
Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT.
ECRI Institute 2018
https://www.ecri.org/Resources/HIT/Closing_Loop/Closing_the_Loop_Toolkit.pdf
Greg’s Wings
Film: Falling Through the Cracks: Greg’s Story
http://gregswings.ca/fttc-gregsstory/
Picard A. Why are fax machines still the norm in
21st-century health care? The Globe and Mail (Toronto, Ontario) 2018; June 11,
2018
Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health
Information Exchange, and Inter-Hospital Transfer Outcomes: a
Population Study. Journal of General Internal Medicine 2018; 33(9): 1447-1453
https://link.springer.com/article/10.1007/s11606-018-4491-x
Print “September
2018 ECRI Institute Partnership: Closing the Loop”
It seems we’ve done all too many columns on the unintended
consequences of healthcare IT. So we’re happy to
highlight this month some success stories for clinical decision support systems
(CDS).
Cedars-Sinai Medical Center integrated select recommendations
from the Choosing Wisely campaign as CDS alerts into their EHR. This included
many alert-based CDS interventions, both inpatient and ambulatory. Providers,
when presented with an alert, had the option to cancel, change, or justify the
order, They analyzed the impact of these
CDS alerts on inpatient encounters (Heekin
2018). The researchers found that encounters in which providers
adhered to all alerts had significantly lower total costs, shorter lengths of
stay, a lower probability of 30-day readmissions, and a lower probability of
complications compared with nonadherent encounters. Full adherence to Choosing
Wisely alerts was associated with savings of $944 from a median encounter cost
of $12,940.
Another recent study (Wachsberg
2018) demonstrated that an educational intervention, combined with
real-time clinical decision support (CDS), reduced blood utilization among
hospitalized solid tumor cancer patients without adversely affecting outcomes.
The odds of receiving a transfusion were cut by almost half in the
postintervention cohort. There were no significant differences in readmission,
outpatient transfusion within seven days of discharge, or inpatient mortality.
Patients in the postintervention cohort also had lower odds of ICU transfer
(OR = 0.29).
And another study in a large academic medical
center (Eaton 2018) showed a mixed impact of nonintrusive
clinical decision support systems on laboratory test utilization, reminding us
to focus on areas where a positive impact is seen and avoid unnecessary alerts
that don’t change outcomes. The study focused on CDS for red blood cell folate,
hepatitis C virus viral loads and genotypes, and (blood) type and screens. Appropriate
indications for these labs were incorporated into text that accompanied the
laboratory orders in the hospital's EHR. There was a 43% decrease in the rate
of hepatitis C virus tests per monthly admissions after the CDS was
implemented. But there was no significant change in type and screen orders or
folate orders. The authors stress that nonintrusive CDS should be evaluated for
individual laboratory tests to ensure only effective alerts continue to be used
so as to avoid increasing EHR fatigue.
The last point is very important. Avoiding
alert fatigue is critical in any clinical decision support program. We stress
to hospitals that they need to have an interdisciplinary group that works with
their IT staff to evaluate the impact of every new CDS rule implemented. That
means looking to see what the adherence/override rate is for each alert and
whether the alert results in the desired change in ordering.
These three studies, however, clearly show
that careful planning, implementation, and evaluation of clinical decision
support tools can be beneficial to patient care and can be done in a manner
that is nonintrusive.
See some of our other
Patient Safety Tip of the Week columns dealing with unintended consequences of
technology and other healthcare IT issues:
References:
Heekin AM, Kontor
J, Sax HC, et al. Choosing Wisely Clinical Decision Support Adherence and
Associated Inpatient Outcomes. Am J Manag Care 2018; 24(8): 361-366
Wachsberg KN, O'Leary KJ, Buck R, et al. Impact of
Real-Time Clinical Decision Support on Blood Utilization and Outcomes in
Hospitalized Patients with Solid Tumor Cancer. The Joint Commission Journal on
Quality and Patient Safety 2018; Published online: August 17, 2018
https://www.jointcommissionjournal.com/article/S1553-7250(17)30485-3/fulltext
Eaton KP, Chida N, Apfel
A, et al. Impact of nonintrusive clinical decision support systems on
laboratory test utilization in a large academic centre.
Journal of Evaluation in Clinical Practice 2018; 24(3): 474-479 First
Published: 15 February 2018
https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.12890
Print “September
2018 More Clinical Decision Support Successes”
In multiple presentations on healthcare policy (outside of
our patient safety activities) we have discussed the impact of mergers and
acquisitions in healthcare. Having participated directly or indirectly in
several mergers, we’ve focused primarily on the financial implications.
Call us skeptics. While every merger promises the community
incredible financial benefit, few deliver on those promises. Theoretically,
mergers should produce much savings by eliminating duplication. But, in reality, such mergers usually result in putting
negotiating clout in one system and eventually rising healthcare costs for the
community.
But until now there has been little attention to the patient safety repercussions of hospital mergers. Haas and colleagues
The authors identified 3 key risks to patient care resulting
from mergers:
Post-merger, patients may be cared for by clinicians and
staff who have little existing knowledge about them. Changes in supplies,
equipment, formularies, protocols, and information systems also lead to
unfamiliarity that may adversely impact patient care. And physicians, especially
specialists, may now be required to travel to new settings where they may be
unfamiliar with infrastructure, processes, teams, and clinical cultures that
may differ significantly from one organization to the other(s).
Importantly, in collaboration with their Ariadne Labs, they
make available for free a guide
and patient safety toolkit to help with clinical planning between
institutions prior to mergers. It also includes a checklist for developing a
joint clinical integration council.
Mergers are not easy on clinicians and healthcare staff and
ultimately may jeopardize patient safety. These resources are extremely
valuable for any organizations considering merger and need to be tapped very
early in any discussions about merger.
References:
Print “September
2018 Mergers and Patient Safety”
Print “September
2018 What's New in the Patient Safety World (full column)”
Print “September
2018 ISMP Updates List of High-Alert Medications”
Print “September
2018 ECRI Institute Partnership: Closing the Loop”
Print “September
2018 More Clinical Decision Support Successes”
Print “September
2018 Mergers and Patient Safety”
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version”
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